Unlisted E/M Service CPT Code 99499 - Initial Hospital Care after Observation

Per the CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.1 "Selection of Level of Evaluation and Management Service":

"In the rare circumstance when a physician (or NPP) provides a service that does not reflect a CPT code description, the service must be reported as an unlisted service with CPT code 99499. A description of the service provided must accompany the claim. The carrier has the discretion to value the service when the service does not meet the full terms of a CPT code description (e.g., only a history is performed)."

Typically, an E/M service must reflect at least the minimum requirements of the lowest level of code in a code family in order to be paid. Providers are instructed to select the highest-level service within a Category or Subcategory of E/M codes for which all criteria are met. If all the criteria for a code are not met, then a lower level code must be selected. CPT 99499 (unlisted service) must be used only in the rare circumstance where the visit does not reflect even the lowest level of E/M service in an applicable CPT code family yet still evidences medical necessity. Supporting documentation must be provided to help a payer determine a payment amount.

CPT 99499 is never to be used to interpolate between two levels of E/M service within a category or subcategory. Rather the next lower code for which all criteria are met is the appropriate choice.

With reference to an inpatient admission that occurs one or more days after a patient's placement in hospital observation status, it is true that the CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.8.

"If the patient is admitted to inpatient status from observation subsequent to the date of admission to observation, the physician must bill an initial hospital visit for the services provided on that date."

The service performed at the time of this transfer to inpatient status, however, must still comply with medical necessity and documentation requirements. Therefore, the following apply, in order:

If an "inpatient admission," CPT calls it initial hospital care not inpatient admission as they are not technically admit codes, (CPT codes 99221, 99222, 99223 or 99291) is necessary, with all required components performed and appropriately documented, then that level of service is appropriate for billing and payment.

If criteria for even CPT 99221 "inpatient admission," CPT calls it initial hospital care not inpatient admission, are not met, but a service was necessary, and all the required components performed and appropriately documented meet criteria for a "subsequent visit" (CPT codes 99231, 99232 or 99233), then that level of service is appropriate for billing and payment (even though the service is chronologically an "admission").

If, in what should be a very rare circumstance, an E/M service is necessary, performed and documented that does not meet even the criteria for CPT 99231, then CPT 99499 may be paid (which requires individual adjudication and pricing based on the submitted documentation).

In what should be a rare circumstance where the provider concludes only CPT 99499 is appropriate, it is the responsibility of the provider to ensure all necessary information has been documented in the medical record. The service must meet medical necessity and reasonableness standards. Documentation must include the place of service and a brief statement why another E /M code does not apply.

A concise description of the type of service is required in Item 19 on the CMS-1500 Claim form or the electronic equivalent. Examples of descriptions include: "office/other outpatient visit," "hospital admission," etc.

Do not send documentation with the claim. Noridian will send a letter requesting documentation for the unlisted E/M service after the claim has been received.



Last Updated Dec 09 , 2022